SAFE LOOK Form-fitting aprons shield surgical team members from the dangers of radiation scatter

You won't see the invisible dangers of repeated exposure to ionized radiation until it's too late. Skin reactions, hair loss, cataracts and infertility can occur within weeks or years of exposure. More serious aliments such as cancer and conditions passed along to your kids might take decades to manifest. Why chance health issues when the latest C-arms and protective gear are designed to protect you from harm?

C-arm safeguards
The surgical team is in danger of exposure to radiation that scatters off of the patient, equipment and OR table. To limit the risk, the International Commission on Radiological Protection (ICRP), which is pushing for stronger regulations for limiting radiation exposure in health care, suggests you stand as far as possible from the X-ray source, which produces the greatest risk of radiation exposure. Instead, stand on the side of the patient where the image intensifier is positioned, especially when the C-arm is placed laterally or obliquely to the patient. That's not always possible. During orthopedic or spine procedures, surgeons might have to stand close to the X-ray source to place an implant. That's when wearing proper personal protection becomes even more important.

Position the X-ray source as far as possible from the patient and the image intensifier as close to the imaging site as possible to reduce the level of radiation that reaches patients' skin. In addition, try to avoid imaging anatomy from oblique or lateral positions to decrease the length radiation must travel through the patient. Position only those body parts that require imaging in the C-arm's field.

It's best to use a C-arm's lowest possible dose rate — rates of 10 pulses per second or less will deliver images suitable for performing most surgeries, says the ICRP — and pulsed fluoroscopy settings to limit the delivered radiation. Newer C-arms sense how much signal is produced at the image receptor based on the thickness of the target anatomy and adjust exposure parameters such as tube voltage (kV) and pulse time to ensure the smallest possible radiation dose is delivered.

Collimate the C-arm's beams to focus on the targeted area, reduce exposure to adjacent tissue and limit the potential for scatter. Start with the collimators closed and gradually open them until only the desired imaging area is in view. Newer machines let you adjust the collimation without activating the fluoroscopy, which is a nice safety feature. Use the last-image-hold feature available on newer machines to study specific anatomy instead of delivering constant fluoroscopy to capture continuous images. Only activate the unit when your attention is on the monitor. Communication between surgeons and techs helps ensure the fluoroscopy is activated only when intended.

FULL COVERAGE Wrap-around aprons provide front-and-back protection.

Layers of protection
It's essential to place a protective shield over areas of the body that have a high rate of rapidly dividing cells, such as the thyroid and gonads, where ionizing radiation mutates the body's DNA.

Cataracts can be caused by long-term exposure to ionized radiation, but lead-lined glasses with side shields decrease exposure by more than 90%. According to the ICRP, aprons of 0.25-mm lead equivalence suffice for procedures performed on pediatric patients and thin individuals, and 0.35-mm lead equivalence offer protection needed for surgeries performed on thick patients or for surgeons and staff who work many imaging procedures. Opt for wrap-around aprons, which provide back-and-front protection. Still, never turn your back on the surgical field when the X-ray is activated.

Lead gowns of at least 0.5-mm thickness reduce exposure to scatter by 90%, says the ICRP, but only if they're properly maintained. Hang — never fold — them in storage. Visually inspect aprons regularly for cracks or tears.

The weight of lead aprons can be a strain, especially to those who work many cases or have back injuries. Consider two-piece aprons, aprons designed to distribute weight to the shoulder flaps or newer lead-free lightweight options that offer comparable protection to 0.5-mm lead equivalent aprons.

Keep your hands out of the line of radiation when X-rays are being taken. There have been reports of sarcomas of the hand developing in surgeons who are repeatedly exposed. A new bismuth-oxide-based hand cream reportedly decreases radiation exposure for those who must keep their hands in the imaging field during procedures — trauma surgeons holding bones together, for example. I've tried the cream, but didn't enjoy the feeling of working with the layer under my gloves. Surgical team members might instead opt for lead-lined gloves or, if possible, focus on removing their hands from the field when the X-ray is activated.

In orthopedics, we roll in moveable lead-lined shields that ancillary staff stand behind when the fluoroscopy is shot. All those present during imaging should wear dosimeter badges. The annual safe thresholds of exposure are 20 mSv for the eye lens, 500 mSv for the skin and 500 mSv for the hands and feet, per ICRP. Monitor the badges monthly or bimonthly — whatever duration the dosimeter manufacturer suggests — to ensure they remain within the safe threshold of exposure. OSM